Standardized illumination for visual acuity testing in clinical research

BCLA CLEAR Presbyopia: Evaluation and diagnosis

It is important to be able to measure the range of clear focus in clinical practice to advise on presbyopia correction techniques and to optimise the correction power. Both subjective and objective techniques are necessary: subjective techniques (such as patient reported outcome questionnaires and defocus curves) assess the impact of presbyopia on a patient and how the combination of residual objective accommodation and their natural DoF work for them; objective techniques (such as autorefraction, corneal topography and lens imaging) allow the clinician to understand how well a technique is working optically and whether it is the right choice or how adjustments can be made to optimise performance. Techniques to assess visual performance and adverse effects must be carefully conducted to gain a reliable end-point, considering the target size, contrast and illumination. Objective techniques are generally more reliable, can help to explain unexpected subjective results and imaging can be a powerful communication tool with patients. A clear diagnosis, excluding factors such as binocular vision issues or digital eye strain that can also cause similar symptoms, is critical for the patient to understand and adapt to presbyopia. Some corrective options are more permanent, such as implanted inlays / intraocular lenses or laser refractive surgery, so the optics can be trialled with contact lenses in advance (including differences between the eyes) to better communicate with the patient how the optics will work for them so they can make an informed choice.

A multilevel investigation of sensory sensitivity and responsivity in autistic adults

Atypical sensory processing is a core symptom of autism spectrum disorders (ASD). We aimed at better characterizing visual sensitivity and responsivity in ASD at the self-reported, behavioral and neural levels, and at describing the relationships between these levels. We refer to sensory sensitivity as the ability to detect sensory stimuli and to sensory responsivity as an affective response to sensory stimuli. Participants were 25 neurotypical and 24 autistic adults. At the self-reported level, autistic participants had higher scores of sensory sensitivity and responsivity than neurotypicals. The behavioral and neural tasks involved contrast-reversing gratings which became progressively (in)visible as their contrast or spatial frequency evolved. At the behavioral level, autistic participants had higher detection and responsivity thresholds when gratings varied in spatial frequency, but their thresholds did not differ from neurotypicals when gratings varied in contrast. At the neural level, we used fast periodic visual stimulations and electroencephalography to implicitly assess detection thresholds for contrast and spatial frequency, and did not reveal any group difference. Higher self-reported responsivity was associated with higher behavioral responsivity, more intolerance of uncertainty and anxiety, in particular in ASD. At the self-reported level, higher sensitivity was associated with more responsivity in both groups, contrary to the behavioral level where these relationships were not found. These heterogeneous results suggest that sensitivity and responsivity per se are not simply increased in ASD, but may be modulated by other factors such as environmental predictability. Multi-level approaches can shed light on the mechanisms underlying sensory issues in ASD.

Line-by-line visual acuity scoring equivalence with letter-by-letter visual acuity scoring

Clinical relevance: A scoring criterion of three-or-more letters correct on a line results in the most equivalent visual acuity score to letter-by-letter scoring.Background: Using the criterion of three-or-more letters correct on a line of five letters to measure a line visual acuity is common. In this study, different line acuity criteria are compared to letter-by-letter visual acuity scoring to determine which criterion is the most accurate as well as least variable.Methods: One eye each of 32 subjects was tested with high-contrast visual acuity charts at 4.88 m. Subjects had 16 acuities measured: 8 under normal conditions and 8 under a + 1.50D blur condition. For each set of 8, logMAR visual acuity results were obtained by retrospectively applying each of four scoring criteria twice: letter-by-letter acuity and three line acuities (three-or-more, four-or-more, or five correct on a line). Differences in means were analysed using repeated measures ANOVA with post-hoc Tukey testing. Test-retest variability was analysed via Bland-Altman analysisResults: The mean visual acuities (in logMAR) were -0.10, -0.11, -0.07, and -0.01 for letter-by-letter, three-or-more correct, four-or-more correct, and all five correct, respectively. With blur, the mean visual acuities were 0.41, 0.39, 0.45, and 0.53 for the respective criteria. Under both normal and blur conditions, the different acuity scoring criteria resulted in significant differences (p < 0.001), except for the letter-by-letter and three-or-more criteria (p ≥ 0.18). Whereas the criteria resulted in similar test-retest variability under blur, the line acuity using a criterion of three-or-more letters correct resulted in the lowest test-retest variability under best-corrected conditions.Conclusion: A line visual acuity scoring criterion of three-or-more letters correct on a line, whether with good visual acuity or poorer visual acuity due to defocus, provides the most similar acuity and test-retest variability compared to letter-by-letter visual acuity.

Sensitivity and Stability of Functional Vision Tests in Detecting Subtle Changes Under Multiple Simulated Conditions

Purpose

To explore whether subtle changes in visual quality can be detected using different measures of visual function against the quick contrast sensitivity function test (quick CSF).

Methods

Sixty participants, aged 17 to 34 years, were enrolled. Participants' vision was degraded by 0.25 D undercorrection (0.25 D), 60% neutral density filter brightness reduction (60% ND), and 0.8 Bangerter foil optical diffusion (0.8BAN). Visual function tests including visual acuity and contrast sensitivity (CSV-1000E and quick CSF) were measured with participant's best-corrected vision and under simulated visual degradation conditions. Test sensitivities in detecting differences were compared.

Results

Statistically significant visual acuity degradation was observed in the 0.8BAN condition only (Pcorrected < 0.001). With CSV-1000E and outliers removed, significant CS degradation was observed in all spatial frequencies, area under log CSF (AULCSF) in the 0.8BAN condition (Pcorrected < 0.001 for all), medium and high spatial frequencies and AULCSF in the 60%ND condition (Pcorrected,6cpd = 0.002, Pcorrected,12cpd = 0.005, Pcorrected,18cpd = 0.001, Pcorrected,AULCSF < 0.001) and the 0.25 D condition (Pcorrected,6cpd = 0.011, Pcorrected,12cpd = 0.013, Pcorrected,18cpd = 0.015, Pcorrected,AULCSF < 0.001). With the quick CSF, significant CS degradation was observed in all simulated visual conditions in all spatial frequencies, cutoff frequency and AULCSF (Pcorrected < 0.001 for all). Test-retest reliability of the quick CSF method was high; coefficient of repeatability ranged from 0.14 to 0.18 logCS.

Conclusions

Compared with visual acuity and chart-based CS tests, the quick CSF method provided more reliable and sensitive measures to detect small visual changes.

Translational Relevance

The quick CSF method can provide sensitive and reliable measures to monitor disease progression and assess treatment outcomes.

Saving space: Comparing mini - logMAR with standard logMAR visual acuity

Purpose:

Assessing visual acuity (VA) is the cornerstone of an ophthalmic workup and needs VA charts in a four or six meters space. The objective of this study was to compare the performance of distant VA (DVA) on one meter mini-logMAR (MLM) with a standard six meter logMAR (SLM) chart.

Methods:

We developed a MLM chart to be used at 1 m with +1.0 D spectacles, by reducing the SLM chart designed for 6 meters, to 1/6^th its size, using AutoCAD version 2014. On an initial cohort, we obtained DVA on the two charts by optometrist trainees, masked to the outcomes on the different tests. We performed regression and checked agreement between the two measurements. Subsequently, on a new cohort, we validated the performance of the MLM.

Results:

Of the 56 initial subjects, mean DVA with SLM was 0.44 ± 0.13 and with MLM was 0.45 ± 0.13; mean difference of -0.01 ± 0.02, 95%CI: 0.007 to 0.018; P < 0.0001 on paired t-test. There was a significant correlation: r = 0.99; r² = 0.98, P < 0.0001. On an average, DVA with MLM was less than a letter worse than with SLM. The regression formula obtained: SLM DVA = -0.1312 + 1.0014 x (MLM DVA). The validation study revealed no significant difference (P = 0.29) between the predicted standard DVA calculated by the regression formula and the actual standard.

Conclusion:

We suggest that we can deduce distance logMAR VA from a mini-logMAR chart as devised and used by us. This will take less space, be portable and allow congenial interaction with patients.

A comparison of visual acuity measured by ETDRS chart and Standard Logarithmic Visual Acuity chart among outpatients

AIM

To compare the results of visual acuity (VA) measured by Early Treatment Diabetic Retinopathy Study (ETDRS) chart, 5 m Standard Logarithm Visual Acuity (5SL) chart, and 2.5 m Standard Logarithm Visual Acuity (2.5SL) chart in outpatients of age 12-80y.

METHODS

Each patient (totally 2000 outpatients) had both eyes tested with ETDRS chart at 4 m, 5SL chart at 5 m, and 2.5SL chart at 2.5 m in random order. The VA values of outpatients were categorized by ages. VA values were expressed by logMAR recording method.

RESULTS

The mean VA results of ETDRS charts, 5SL, and 2.5SL chart were 0.52±0.28, 0.50±0.30, and 0.46±0.28 logMAR, respectively. There was a statistically significant difference in the three eye charts in the whole group (P<0.001). For all subjects, the correlation of VA tested with three charts was statistically significant (Spearman correlation coefficient=0.944, 0.937, 0.946, all P<0.001). Bland-Altman analysis shows the 95% limits of agreement between the 5SL and 2.5SL chart were -0.182 to 0.210, -0.139 to 0.251, and -0.151 to 0.235 logMAR, respectively).

CONCLUSION

The agreement between the three eye charts is not high. The VA measured by 5SL chart is slightly better than that by ETDRS chart and 5SL chart would be a suitable alternative when ETDRS chart are not available in the clinical situation. The VA measured by 2.5SL chart is about 0.5 line better than VA tested with ETDRS chart, which may overestimate VA.

Visual Function and Visual Acuity in An Urban Adult Population

In this survey, 6,850 Baltimore residents aged 40 and older were interviewed about activities they had difficulty doing or could no longer do because of poor vision. One-fourth of the sample reported limitations in activities, most frequently reading and other near-vision tasks, because of poor vision. In addition to poor vision, general health status, educational level, and time since the last eye care visit were associated with the loss of visual function.

Monitoring progression of retinitis pigmentosa: current recommendations and recent advances

INTRODUCTION

Retinitis pigmentosa (RP) is the most common form of inherited retinal degenerations with an estimated prevalence of 1 in 4,000 and more than 1 million individuals affected worldwide. With the introduction of the first retinal gene therapy in 2017 the importance of understanding the mechanisms of retinal degeneration and its natural progression has shifted from being of academic interest to being of pivotal for the development of new therapies.

AREAS COVERED

This review covers standard and innovative diagnostic techniques and complementary examinations needed for the evaluation and treatment of RP. It includes chapters on the assessment of visual function, retinal morphology, and genotyping.

EXPERT OPINION

Monitoring the progression of RP can best be achieved by combining assessments of both visual function and morphology. Visual acuity testing using ETDRS charts should be complemented by low-luminance visual acuity and colour vision tests. Assessment of the visual field can also be useful in less advanced cases. In those with central RP involvement measuring retinal sensitivity using microperimetry is recommended. Retinal morphology is best assessed by OCT and autofluorescence. Genetic testing is pivotal as it contributes to the pathophysiological understanding and can guide clinical management as well as identify individuals that could benefit from retinal gene therapy.

Repeatability and Agreement of Visual Acuity Using the ETDRS Number Chart, Landolt C Chart, or ETDRS Alphabet Chart in Eyes With or Without Sight-Threatening Diseases

Importance

The Early Treatment Diabetic Retinopathy Study (ETDRS) alphabet chart is not feasible for measuring best-corrected visual acuity (BCVA) for individuals who are unfamiliar with the Roman alphabet. The ETDRS Landolt C chart is an alternative, but it may not reflect true BCVA among those with confusion between left and right. The ETDRS number chart might overcome these limitations, but little is known regarding its reliability.

Objective

To evaluate repeatability and agreement of BCVA using the ETDRS number chart or Landolt C chart compared with ETDRS alphabet charts in healthy and diseased eyes.

Design, Setting, and Participants

A cross-sectional study was conducted in Thailand from July 1, 2015, to June 30, 2016, among 154 adult Thai individuals. Those who could read Roman alphabets were classified into the following 4 groups, using 1 eye per participant: group A, which comprised 60 healthy eyes (BCVA, 20/20-20/25); group B, which comprised 40 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/20-20/40); group C, which comprised 40 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/50-20/100); and group D, which comprised 14 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/125-20/200).

Interventions

Two standardized 4-m BCVA measurements with 3 different Precision Vision ETDRS charts (PV number, Landolt C, and alphabet), in random sequence, performed 30 minutes apart.

Main Outcomes and Measures

Repeatability, agreement, and testing duration of BCVA.

Results

Of 154 Thai participants (82 women and 72 men; mean [SD] age, 52.9 [18.2] years), the ETDRS number chart had strong repeatability coefficients (group A, 0.61 [95% CI, 0.42-0.75]; group B, 0.87 [95% CI, 0.78-0.93]; group C, 0.81 [95% CI, 0.67-0.90]; and group D, 0.81 [95% CI, 0.49-0.94]). Concordance correlation coefficients between the number and alphabet charts were also strong (group A, 0.89 [95% CI, 0.82-0.93]; group B, 0.97 [95% CI, 0.94-0.98]; group C, 0.92 [95% CI, 0.86-0.96]; and group D, 0.96 [95% CI, 0.87-0.99]), while the concordance correlation coefficients between the Landolt C and alphabet charts were lower (group A, 0.72 [95% CI, 0.52-0.83]; group B, 0.83 [95% CI, 0.68-0.91]; group C, 0.79 [95% CI, 0.61-0.89]; and group D, 0.89 [95% CI, 0.66-0.97]). The mean letter score difference between the number and alphabet charts was 1 (95% limits of agreement, -4 to +6) compared with -7 (95% limits of agreement, -18 to +5; P < .001) between the Landolt C and alphabet charts.

Conclusions and Relevance

The repeatability coefficients and concordance correlation coefficients suggest that ETDRS number charts are viable for measuring BCVA in clinical practice and trials for individuals who are unfamiliar with the Roman alphabet.

Long-term Safety and Ocular Hypotensive Efficacy Evaluation of Netarsudil Ophthalmic Solution: Rho Kinase Elevated IOP Treatment Trial (ROCKET-2)

PURPOSE

To evaluate netarsudil 0.02% ophthalmic solution in patients with open-angle glaucoma (OAG) and ocular hypertension (OHT).

DESIGN

Double-masked, randomized, multicenter, parallel-group, noninferiority clinical study.

METHODS

After a washout of all prestudy ocular hypotensive medications, 756 eligible patients with elevated IOP were randomized to receive netarsudil 0.02% once a day (q.d.) (251); netarsudil 0.02% twice a day (b.i.d.) (254); or timolol 0.5% b.i.d. (251) for 12 months, as well as a noninterventional Corneal Observation Study (COS) for patients manifesting cornea verticillata.

RESULTS

On treatment, mean IOP at 8:00 AM decreased from a baseline IOP of 22.5-22.6 mm Hg to 17.9-18.8 mm Hg, 17.2-18.0 mm Hg, and 17.5-17.9 mm Hg for netarsudil q.d., netarsudil b.i.d., and timolol, respectively, over 12 months. The most frequently reported adverse events (AEs) were ocular, with the most frequent ocular AE being conjunctival hyperemia, with an incidence of 61%, 66%, and 14%, respectively. The next most frequent AEs were corneal deposits (corneal verticillata), with an incidence of 26%, 25%, and 1%, respectively, and conjunctival hemorrhage (typically petechial), with an incidence of 20%, 19%, and 1%, respectively. All 3 AEs were generally scored as mild, with conjunctival hyperemia and/or hemorrhage appearing sporadically during the study. In the observational follow-up component of this study, there was no clinically meaningful impact of corneal verticillata on visual function in affected patients.

CONCLUSIONS

In this randomized, double-masked trial, once-daily dosing of netarsudil 0.02% was effective, consistently lowering IOP through 12 months, and was tolerated by the majority of patients.

Development of Corneal Astigmatism (CA) according to Axial Length/Corneal Radius (AL/CR) Ratio in a One-Year Follow-Up of Children in Beijing, China

Purpose

The correlations between the axial length-to-corneal radius (AL/CR) ratio and corneal astigmatism (CA) were studied by prospectively analyzing and comparing survey data from school children in the Beijing urban area from 2014 to 2015.

Methods

In this longitudinal study, a total of 2,970 students were enrolled in 2014, and 2,179 students were enrolled in 2015. The students were in grades 1 and 4 of primary schools located in the Yangfangdian district of Beijing. The students were examined using the standard logarithmic visual acuity chart for uncorrected visual acuity (UCVA) and IOLMaster for ocular components.

Results

From 2014 to 2015, the students from grades 1 and 4 had significantly worse UCVA results, longer axial lengths (AL), and greater AL/CRs (p < 0.001). The boys had a longer AL and corneal radius (CR) than the girls (p < 0.001). A significantly higher rate of increased CA was observed for the students with increased AL/CR than for those with decreased or unchanged ratios (AL/CR for grade 1, X² = 12.304, p=0.001; for grade 4, X² = 29.044, p < 0.001). In addition, with increased AL/CR over one year, the CA value of the students in grades 1 and 4 became significantly larger (grade 1, p=0.001; grade 4, p < 0.001); moreover, the UCVA became worse (p < 0.001).

Conclusions

We found that UCVA and AL growth were affected by aging. An increase in the AL/CR ratio is a risk factor for the progression of corneal astigmatism for school children.

History of falling and visual ability among independently living elderly in Sweden

Purpose

The aim of this study was to assess the performance-based visual ability among independently living elderly subjects and to investigate whether there was any association between visual ability and falls.

Subjects and methods

A total of 298 randomly selected subjects aged 70–85 years were invited for an examination including monocular and binocular visual acuity (VA), contrast sensitivity (CS), stereoscopic vision, and monocular visual fields (VFs), which were integrated to estimate the binocular VFs. Type of lenses used in their habitual correction was noted.

Results

Out of the 212 subjects who were examined, 38% reported at least one fall and 48% of these reported at least two falls during the last 2 years. Most subjects had normal results; 90% had normal binocular VA, 85% had normal binocular CS, and ~80% had positive stereopsis. Twenty-nine subjects had VF defects in the lower quadrants of the binocular VF, and 14 of these reported at least one fall. A significant association was seen between one fall or more and VA better eye, the odds ratio (OR) was 2.26, P=0.013, and between recurrent falls and lack of stereoscopic vision, the OR was 3.23, P=0.002; no other functional test showed any significant association with recurrent falls. The ORs were 1.58 for worse binocular VA, 0.60 for worse binocular CS, and 0.71 for non-normal stereoscopic vision for at least one fall, but wide confidence intervals made it difficult to draw firm conclusions about any association. Bifocal or progressive spectacles were worn by 71% with no significant difference between fallers and nonfallers (P=0.078).

Conclusion

Even though ~40% of the total sample had experienced one or more falls, the only visual function test significantly associated with falls were VA better eye, lack of stereoscopic vision, and recurrent falls. Our results suggest that there may be more powerful predictors of falling than decreased visual ability.

Fiat Lux: the effect of illuminance on acuity testing

Purpose

To determine the effect of changing illuminance on visual and stereo acuity.

Methods

Twenty-eight subjects aged 21 to 60 years were assessed. Monocular visual acuity (ETDRS) of emmetropic subjects was assessed under 15 different illuminance levels (50–8000 lux), provided by a computer controlled halogen lighting rig. Three levels of myopia (−0.50DS, −1.00DS & 1.50DS) were induced in each subject using lenses and visual acuity (VA) was retested under the same illuminance conditions. Stereoacuity (TNO) was assessed under the same levels of illuminance.

Results

A one log unit change in illuminance level (lx) results in a significant change of 0.060 LogMAR (p < 0.001), an effect that is exacerbated in the presence of induced myopic refractive error (p < 0.001). Stereoacuity scores demonstrate statistically significant overall differences between illuminance levels (p < 0.001).

Conclusions

The findings of this study demonstrate that changes in illuminance have a statistically significant effect on VA that may contribute to test/retest variability. Increases in illuminance from 50 to 500 lx resulted in an improved VA score of 0.12 LogMAR. Differences like these have significant clinical implications, such as false negatives during vision screening and non-detection of VA deterioration, as the full magnitude of any change may be hidden. In research where VA is a primary outcome measure, differences of 0.12 LogMAR or even less could affect the statistical significance and conclusions of a study. It is recommended that VA assessment always be performed between 400 lx and 600 lx, as this limits any effect of illuminance change to 0.012 LogMAR.

Factors Predicting Visual Acuity Outcome in Intermediate, Posterior, and Panuveitis: The Multicenter Uveitis Steroid Treatment (MUST) Trial

PURPOSE

To identify factors associated with best-corrected visual acuity (BCVA) presentation and 2-year outcome in 479 intermediate, posterior, and panuveitic eyes.

DESIGN

Cohort study using randomized controlled trial data.

METHODS

Multicenter Uveitis Steroid Treatment (MUST) Trial masked BCVA measurements at baseline and at 2 years follow-up used gold-standard methods. Twenty-three clinical centers documented characteristics per protocol, which were evaluated as potential predictive factors for baseline BCVA and 2-year change in BCVA.

RESULTS

Baseline factors significantly associated with reduced BCVA included age ≥50 vs <50 years; posterior vs intermediate uveitis; uveitis duration >10 vs <6 years; anterior chamber (AC) flare >grade 0; cataract; macular thickening; and exudative retinal detachment. Over 2 years, eyes better than 20/50 and 20/50 or worse at baseline improved, on average, by 1 letter (P = .52) and 10 letters (P < .001), respectively. Both treatment groups and all sites of uveitis improved similarly. Factors associated with improved BCVA included resolution of active AC cells, resolution of macular thickening, and cataract surgery in an initially cataractous eye. Factors associated with worsening BCVA included longer duration of uveitis (6-10 or >10 vs <6 years), incident AC flare, cataract at both baseline and follow-up, pseudophakia at baseline, persistence or incidence of vitreous haze, and incidence of macular thickening.

CONCLUSIONS

Intermediate, posterior, and panuveitis have a similarly favorable prognosis with both systemic and fluocinolone acetonide implant treatment. Eyes with more prolonged/severe inflammatory damage and/or inflammatory findings initially or during follow-up have a worse visual acuity prognosis. The results indicate the value of implementing best practices in managing inflammation.

EXTEND II: an open-label phase III multicentre study to evaluate efficacy and safety of ranibizumab in Chinese patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration

PURPOSE

To evaluate the efficacy and safety of monthly ranibizumab 0.5 mg in Chinese patients with subfoveal choroidal neovascularization (CNV) secondary to neovascular age-related macular degeneration (nAMD).

METHODS

A 12-month open-label single-arm multicenter phase III study that included treatment-naïve (study eye) patients with primary/recurrent subfoveal CNV secondary to AMD. Patients (N = 114) aged ≥50 years with best-corrected visual acuity (BCVA) of 73-24 letters were treated with monthly ranibizumab for 12 months. Main outcomes were mean BCVA change from baseline to month 4 (primary endpoint) and over time to month 12, effects of ranibizumab treatment on retinal structure (months 4 and 12), and safety.

RESULTS

Ranibizumab led to significant improvements in mean BCVA ± standard error (SE) at both months 4 and 12 versus baseline (+9.5 ± 1.10 letters, 95 % confidence interval [CI] 7.3-11.7, and +12.7 ± 1.14 letters, 95 % CI 10.4-14.9, respectively, both P < 0.0001). Ranibizumab prevented loss of vision (≥0 letters BCVA gain) in 91.2 % of patients. Mean central retinal thickness ± SE reduced from baseline to month 12 (-119.9 ± 12.97 µm, 95 % CI -145.59 to -94.20, P < 0.0001). No new safety findings were reported in this study.

CONCLUSION

Ranibizumab administered monthly over 12 months was effective in improving BCVA and was well-tolerated in Chinese nAMD patients.

Fixed-dose combination of AR-13324 and latanoprost: a double-masked, 28-day, randomised, controlled study in patients with open-angle glaucoma or ocular hypertension

BACKGROUND/AIMS

To evaluate the ocular hypotensive efficacy of fixed-dose combinations of the Rho kinase inhibitor and norepinephrine transport inhibitor AR-13324 (0.01% and 0.02%) and latanoprost (PG324 Ophthalmic Solution) relative to the active components AR-13324 0.02% and latanoprost 0.005%, used bilaterally at night.

METHODS

This was a double-masked, randomised, parallel comparison study in patients with open-angle glaucoma or ocular hypertension. After washout, patients were randomised to one of four treatment arms and treated for 28 days. The primary efficacy variable was mean diurnal intraocular pressure (IOP) at day 29.

RESULTS

We randomised 298 patients, of whom 292 (98%) completed the study. Mean unmedicated diurnal IOPs (study eye) was 25.1, 25.1, 26.0 and 25.4 in the PG324 0.01%, PG324 0.02%, latanoprost and AR-13324 0.02% groups, respectively. On day 29, mean diurnal IOP decreased to 17.3, 16.5, 18.4 and 19.1 mm Hg, respectively. For the primary efficacy variable of mean diurnal IOP at day 29, PG324 0.02% met the criterion for statistical superiority relative to both latanoprost and AR-13324 0.02% (p<0.0001), providing additional IOP lowering of 1.9 and 2.6 mm Hg, respectively. PG324 0.01% also met the criterion for superiority. The most frequently reported adverse event was conjunctival hyperaemia with an incidence of 41% (30/73), 40% (29/73), 14% (10/73) and 40% (31/78) in the PG324 0.01%, PG324 0.02%, latanoprost and AR-13324 0.02% groups, respectively.

CONCLUSIONS

In this short-term study, the fixed-dose combination of AR-13324 0.02% and latanoprost 0.005% in PG324 Ophthalmic Solution provides clinically and statistically superior ocular hypotensive efficacy relative to its individual active components at the same concentrations. The only safety finding of note was transient asymptomatic conjunctival hyperaemia which was typically of mild severity.

TRIAL REGISTRATION NUMBER

NCT02057575.

Changes in lens opacities on the age-related eye disease study grading scale predict progression to cataract surgery and vision loss: age-related eye disease study report no. 34

PURPOSE

To investigate whether the 2-year change in lens opacity severity on the Age-Related Eye Disease Study (AREDS) lens grading scale predicts progression to cataract surgery or loss of visual acuity by 5 years.

DESIGN

Prospective cohort study within a randomized clinical trial of oral supplements.

PARTICIPANTS

The AREDS participants whose eyes were phakic at baseline and free of late age-related macular degeneration throughout the study.

METHODS

Baseline and annual lens photographs of AREDS participants (n = 3466/4757; 73%) were graded for severity of cataracts using the AREDS system for classifying cataracts from photographs. Clinical examinations conducted semiannually collected data on cataract surgery and visual acuity. Association of the change in lens opacities at 2 years with these outcomes at 5 years was analyzed with adjusted Cox proportional hazard models.

MAIN OUTCOME MEASUREMENTS

Progression of lens opacities on stereoscopic lens photographs at 2 years, cataract surgery, and visual acuity loss of 2 lines or more at 5 years.

RESULTS

The adjusted hazard ratios (HRs) for association of progression to cataract surgery at 5 years were: nuclear cataract increase of 1.0 unit or more compared with less than 1.0-unit change at 2 years, 2.77 (95% confidence interval [CI], 2.07-3.70; P < 0.001); cortical cataract increase of 5% or more in lens opacity in the central 5 mm of the lens compared with less than 5% increase at 2 years, 1.91 (95% CI, 1.27-2.87; P = 0.002); and posterior subcapsular cataract increase of 5% or more versus less than 5% in the central 5 mm of the lens, 8.25 (95% CI, 5.55-12.29; P < 0.001). Similarly, HRs of vision loss of 2 lines or more at 5 years for this degree of lens changes at 2 years were the following: nuclear, 1.83 (95% CI, 1.49-2.25; P < 0.001); cortical, 1.13 (95% CI, 0.78-1.65; P = 0.519); and posterior subcapsular cataract, 3.05 (95% CI, 1.79-5.19; P < 0.001).

CONCLUSIONS

Two-year changes in severity of lens opacities on the AREDS lens grading scale are predictive of long-term clinically relevant outcomes, making them potential surrogate end points in follow-up studies.

Reliability of a standardized test in Swedish for evaluation of reading performance in healthy eyes. Interchart and test-retest analyses

PURPOSE

The purpose of our study was to establish a practical and quick test for assessing reading performance and to statistically analyse interchart and test-retest reliability of a new standardized Swedish reading chart system consisting of three charts constructed according to the principles available in the literature.

METHODS

Twenty-four subjects with healthy eyes, mean age 65 ± 10 years, were tested binocularly and the reading performance evaluated as reading acuity, critical print size and maximum reading speed. The test charts all consist of 12 short text sentences with a print size ranging from 0.9 to -0.2 logMAR in approximate steps of 0.1 logMAR. Two testing sessions, in two different groups (C1 and C2), were under strict control of luminance and lighting environment. Reading performance tests with chart T1, T2 and T3 were used for evaluation of interchart reliability and test data from a second session 1 month or more apart for the test-retest analysis.

RESULTS

The testing of reading performance in adult observers with short sentences of continuous text was quick and practical. The agreement between the tests obtained with the three different test charts was high both within the same test session and at retest.

CONCLUSION

This new Swedish variant of a standardized reading system based on short sentences and logarithmic progression of print size provides reliable measurements of reading performance and preliminary norms in an age group around 65 years. The reading test with three independent reading charts can be useful for clinical studies of reading ability before and after treatment.

Self-rated driving habits among older adults with clinically-defined mild cognitive impairment, clinically-defined dementia, and normal cognition

Older adults with clinically-defined dementia may report reducing their driving more than cognitively normal controls. However, it is unclear how these groups compare to individuals with clinically-defined mild cognitive impairment (MCI) in terms of driving behaviors. The current study investigated self-reported driving habits among adults age 60 and older with clinical MCI (n=41), clinical mild dementia (n=40), and normal cognition (n=43). Participants reported their driving status, driving frequency (days per week), and how often they avoided accessing the community, making left turns, driving at night, driving in unfamiliar areas, driving on high-traffic roads, and driving in bad weather. After adjusting for education, a MANCOVA revealed that participants with MCI and dementia avoided unfamiliar areas and high-traffic roads significantly more than normal participants. Participants with dementia also avoided left turns and accessing the community more than those with normal cognition and MCI (p<0.05 for all). The other driving variables did not significantly differ between groups. Thus, older adults with clinically-defined MCI, as well as those with dementia, avoided some complex driving situations more than cognitively intact adults. However, all diagnostic groups had similar rates of driving cessation and frequency. Future research should examine the safety implications of such findings.

Cataract surgery in patients with Fuchs' endothelial corneal dystrophy: when to consider a triple procedure

PURPOSE

To ascertain preoperative and intraoperative factors that predict the need for endothelial keratoplasty (EK) in patients with Fuchs' endothelial corneal dystrophy (FECD) undergoing cataract surgery.

DESIGN

Prospective, observational cohort study.

PARTICIPANTS

Eighty-nine patients (89 eyes) with FECD who require cataract surgery.

METHODS

One month before cataract surgery, we assessed best-corrected visual acuity, contrast sensitivity, straylight, keratometry, ultrasonic pachymetry, intraocular pressure, 7 corneal features of FECD and cataract density at slit-lamp examination, and corneal backscatter using in vivo confocal microscopy (IVCM; Confoscan 4, NIDEK Technologies, Padova, Italy). After surgery, measurements were repeated at 1, 2, and 12 months. We used stepwise binary logistic regression analysis to evaluate 30 preoperative and 5 intraoperative parameters for their ability to predict the postoperative need for EK. Receiver operating characteristic (ROC) curves of the predictive factors were used to identify their optimal cutoff points.

MAIN OUTCOME MEASURES

Central corneal thickness (CCT) and backscatter at the basal epithelial cell layer (EV).

RESULTS

After cataract surgery, 35 (39%) of 89 eyes underwent EK to restore vision. Of all preoperative and intraoperative parameters, only CCT and EV were identified as significant factors, predictive of the need for EK. The area under the ROC curve of EV was significantly higher than that of CCT (P = 0.003), whereas a combination of both factors in a linear discriminant function did not improve the predictive value (P = 0.66). As optimal cutoff points, we chose 1894 scatter units for EV and 630 μm for CCT. Both cutoff points correspond with a specificity of 94% and represent sensitivity of 63% for EV and 40% for CCT.

CONCLUSIONS

Backscatter at the basal epithelial cell layer measured by IVCM predicts the need for EK after cataract surgery in patients with FECD. As an indicator for the corneal hydration state, the EV improves patient selection for combined cataract surgery and EK. In deciding whether to perform a triple procedure, CCT remains a less effective, but adequate, alternative. Regardless of the predictive factor used, a tailor-made approach is recommended accounting for individuals' expectations.

Comparing LEA numbers low vision book and Feinbloom visual acuity charts

PURPOSE

This study aims to determine the accuracy and repeatability of visual acuity measurements taken with the LEA numbers low vision book (LNLVB) and the Feinbloom chart in visually impaired subjects.

METHODS

Distance visual acuities were taken with the LNLVB, the Feinbloom chart, and the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart, then repeated 15 to 30 min later to evaluate for inter-test repeatability. To determine threshold, participants were encouraged to guess until they could not identify any optotypes. The total number of correctly identified optotypes was recorded and extrapolated to logMAR on all three charts. The Feinbloom chart and LNLVB were evaluated for correlation to ETDRS. Nine visually impaired children and nine visually impaired adults participated in the study.

RESULTS

In comparing the LNLVB to ETDRS, the 95% limits of agreement were +0.099/-0.240, and the correlation coefficient (R) was 0.953 (p < 0001). The same comparison for the Feinbloom chart vs. ETDRS was +0.169/-0.322 with r = 0.905 (p < 0.0001). On test-retest comparisons, the ETDRS was highest with the 95% limits of agreement of +0.117/-0.128. LNLVB and Feinbloom were nearly identical at +0.159/-0.200 and +0.184/-0.202, respectively. The R value for ETDRS was 0.976, LNLVB was 0.954, and Feinbloom was 0.942 (p < 0.0001 on all three).

CONCLUSIONS

The results of our study indicate that there is a slight advantage, in terms of agreement with ETDRS, of LNLVB over the Feinbloom chart when testing visually impaired patients. The two tests proved nearly identical in terms of repeatability in a low-vision setting. Both handheld charts measured slightly worse acuity than the ETDRS chart, but overall proved to be suitable alternatives when the ETDRS chart is not available or practical in certain clinical situations.

Vision assessment using the NIH Toolbox

Vision is a sensation that is created from complex processes and provides us with a representation of the world around us. There are many important aspects of vision, but visual acuity was judged to be the most appropriate vision assessment for the NIH Toolbox for Assessment of Neurological and Behavioral Function, both because of its central role in visual health and because acuity testing is common and relatively inexpensive to implement broadly. The impact of visual impairments on health-related quality of life also was viewed as important to assess, in order to gain a broad view of one's visual function. To test visual acuity, an easy-to-use software program was developed, based on the protocol used by the E-ETDRS. Children younger than 7 years were administered a version with only the letters H, O, T, and V. Reliability and validity of the Toolbox visual acuity test were very good. A 53-item vision-targeted, health-related quality of life survey was also developed.

Effect of blur and subsequent adaptation on visual acuity using letter and Landolt C charts: differences between emmetropes and myopes

PURPOSE

To compare the effects of defocus induced blur and blur adaptation on visual acuity and to evaluate any differences between emmetropes and myopes using letter and Landolt C logMAR charts.

METHODS

The sample consisted of 26 volunteers, with a mean age of 27 ± 3 years, comprising 13 emmetropes (spherical equivalent range: -0.63 to +0.50 D) and 13 myopes (spherical equivalent range: -0.75 to -5.00 D). Monocular visual acuity (VA) was measured in each eye using letter and Landolt C logMAR charts under the following conditions: (1) with the distance refractive correction, (2) immediately after exposure to +2.00 D defocus and (3) following 60 min of binocular adaptation to +2.00 D blur. Objective refraction at the beginning and at the end of the experimental procedure was evaluated. Averaged VA data between the two eyes were used for analysis.

RESULTS

Deterioration in VA with +2.00 D defocus was greater in the emmetropes compared to myopes for both charts. The mean difference between the two refractive groups was more pronounced for the Landolt-C (0.17 logMAR) compared to the letter chart (0.10 logMAR). The reduction in VA with blur was related to the amount of the refractive error. Following 60 min of adaptation, a significant improvement in VA was observed in both groups that did not differ between the two charts. The improvement in VA following adaptation using the letter chart was linearly correlated with spherical equivalent refractive correction.

CONCLUSIONS

Myopes show higher tolerance to retinal defocus compared to emmetropes, which could be attributed to previous blur experience. The effect of blur on VA is more pronounced using Landolt C optotypes than with letters. Prolonged exposure to blur results in equally improved performance for both refractive groups.

The impact of macular edema on visual function in intermediate, posterior, and panuveitis

PURPOSE

To evaluate the impact of macular edema on visual acuity and visual field sensitivity in uveitis.

DESIGN

This study utilized baseline data from the Multicenter Uveitis Steroid Treatment (MUST) Trial, a randomized, parallel treatment clinical trial comparing alternative treatments for intermediate, posterior and panuveitis.

PATIENTS & METHODS

255 patients (481 eyes with uveitis) recruited at 23 subspecialty centers. Visual acuity, optical coherence tomography and Humphrey 24-2 visual field testing.

RESULTS

Macular edema was associated with impaired visual acuity (p < 0.01). Different phenotypes of macular edema were associated with different degrees of visual impairment: cystoid changes without retinal thickening were associated with moderately impaired visual acuity (-5 ETDRS letters), but visual acuity was worse in eyes with retinal thickening (-13 letters) and with both cysts and thickening (-19 letters). Uveitis sufficient to satisfy the study's inclusion criteria was associated with impaired visual field sensitivity, but eyes with macular edema had even worse visual field sensitivity (p < 0.01).

CONCLUSIONS

The observation that macular edema substantially reduces visual function suggests macular edema itself is an important endpoint to study in the treatment of uveitis. As uveitis and macular edema both impair visual field sensitivity as measured by Humphrey 24-2 perimetry, both should be considered when evaluating patients with uveitis and raised intraocular pressure for glaucoma.

Contact lens characteristics and contrast sensitivity of patients with keratoconus

OBJECTIVES

The aim was to describe the contact lens characteristics and contrast sensitivity of patients with keratoconus managed conservatively with contacts lenses at a tertiary eye center in Singapore.

METHODS

A prospective cross-sectional study of 116 patients with clinically evident or suspected keratoconus (on videokeratography) recruited over 11 months. Demographic and medical details, visual acuity (VA) and refraction, corneal topography and contact lens characteristics were documented. Contrast sensitivity with contact lenses was performed with the Vision Contrast Test System 6500 under standardized conditions.

RESULTS

Overall, 67% of the study patients were wearing contact lenses. Of the 129 eligible eyes analyzed, there were 108 eyes with keratoconus and 21 eyes with keratoconus suspect, and 94% were fitted with rigid gas permeable (RGP) lenses. Proprietary keratoconus design lenses were fitted in 74.9% of keratoconus eyes and 30.0% of suspect eyes. With contact lens wear, 83.3% of keratoconus eyes and 100% of suspect eyes achieved 0.3 vision. Mean contrast sensitivity curves of eyes with keratoconus and keratoconus suspect were found to be within normal, although contrast sensitivity in the keratoconus group was consistently lower.

CONCLUSIONS

Most of our patients were managed conservatively with contact lenses, and keratoconus design RGP lenses were the most common type fitted. Good VA can be achieved, but patients with keratoconus may still experience a reduction in contrast sensitivity.

The chronic care for age-related macular degeneration study (CHARMED): study protocol for a randomized controlled trial

Background

Neovascular age-related macular degeneration is the leading cause of irreversible blindness in people 50 years of age or older in the developed world. As in other chronic diseases, several effective treatments are available, but in clinical daily practice there is an evidence performance gap. The Chronic Care Model represents an evidence-based framework for the care of chronically ill patients and aims at closing that gap. However, no data are available regarding patients with neovascular age-related macular degeneration.

Methods/Design

CHARMED is a multicenter randomized controlled trial. The study challenges the hypothesis that the implementation of core elements of the Chronic Care Model (patient empowerment, delivering evidence based information, clinical information system, reminder system with structured follow up and frequent monitoring) via a specially trained Chronic Care Coach in Swiss centres for neovascular age-related macular degeneration results in better visual acuity (primary outcome) and an increased disease specific quality of life (secondary outcome) in patients with neovascular age-related macular degeneration. According to the power calculation, a total sample size of 352 patients is needed (drop out rate of 25%). 14 specialised medical doctors from leading ophtalmologic centres in Switzerland will include 25 patients. In each centre, a Chronic Care Coach will provide disease specific care according to the Chronic Care Model for intervention group. Patients from the control group will be treated as usual. Baseline measurements will be taken in month III - XII, starting in March 2011. Follow-up data will be collected after 6 months and 1 year.

Discussion

Multiple studies have shown that implementing Chronic Care Model elements improve clinical outcomes as well as process parameters in different chronic diseases as osteoarthritis, depression or e.g. the cardiovascular risk profile of diabetes patients. This study will be the first to assess this approach in neovascular age-related macular degeneration. If our hypothesis will be confirmed, the implementation of this approach in routine care for patients with with neovascular age-related macular degeneration should be considered.

Trial Registration

Current controlled trials ISRCTN32507927.

Psychophysical measures of visual acuity in autism spectrum conditions

Previously reported superior visual acuity (VA) in autism spectrum conditions (ASC) may have resulted from methodological settings used (Ashwin, Ashwin, Rhydderch, Howells, & Baron-Cohen, 2009). The current study re-tested whether participants with (N=20) and without (N=20) ASC differ on psychophysical measures of VA. Participants' vision was corrected before acuity measurement, minimising refractive blur. VA was assessed with an ETDRS chart as well as the Freiburg Visual Acuity and Contrast Test (FrACT). FrACT testing was undertaken at 4m (avoiding limitations of pixel-size), using 36 trials (avoiding fatigue). Best corrected VA was significantly better than the initial habitual acuity in both groups, but adults with and without ASC did not differ on ETDRS or FrACT binocular VA. Future research should examine at which level of visual processing sensory differences emerge.

The personal burden of decreased vision-targeted health-related quality of life in nursing home residents

OBJECTIVE

To present the bother subscales of the Nursing Home Vision-Targeted Health-Related Quality of Life Questionnaire (NHVQoL) and to examine their relationship to the original NHVQoL subscales and objective measures of visual function.

METHOD

395 nursing home residents completed the bother subscales. Associations between bother subscales and original subscales and objectively measured vision were evaluated.

RESULTS

Mean bother scores ranged from 1.97 to 2.30, reflecting an average rating of "a little" bother. For 20 NHVQoL items, more than 50% of participants reported "a lot" of bother. All NHVQoL original subscale scores were moderately correlated with bother subscales (p < .0001). Bother subscales and visual acuity were not highly correlated.

DISCUSSION

Nursing home residents are bothered by reductions in vision-targeted health-related quality of life. The NHVQoL bother subscales may probe the personal burden of visual problems in this population that is not captured by the original subscales or objectively measuring visual function.

N-acetylcarnosine lubricant eyedrops possess all-in-one universal antioxidant protective effects of L-carnosine in aqueous and lipid membrane environments, aldehyde scavenging, and transglycation activities inherent to cataracts: a clinical study of the new vision-saving drug N-acetylcarnosine eyedrop therapy in a database population of over 50,500 patients

The antioxidant activity of L-carnosine (beta-alanyl-L-histidine, bioactivated in ocular tissues) versus N-acetylcarnosine (N-acetyl-beta-alanyl-L-histidine, ocular-targeted small dipeptide molecules) was studied in aqueous solution and in a lipid environment, employing liposomes as a model of lipid membranes. Reactive oxygen species (ROS) were generated by an iron/ascorbate promoter system for induction of lipid peroxidation (LPO). L-carnosine, which is stabilized from enzymatic hydrolysis, operates as a universal aldehyde and ROS scavenger in both aqueous and lipid environments and is effective at preventing ROS-induced damage to biomolecules. Second-generation carnosine analogs bearing the histidyl-hydrazide moiety were synthesized and tested versus L-carnosine for their ability to reverse the glycation process, also known as the Maillard reaction, and reverse the stable intermolecular cross-links, monitored in the glucose-ethylamine Schiff base model, ultimately resulting in the formation of the advanced glycation end products (AGEs) from nonenzymatic glycation, accumulating in numerous body tissues and fluids. The obtained data demonstrate the transglycation properties of the ophthalmically stabilized L-carnosine and L-carnosine histidyl-hydrazide derivatives tested and can be used to decrease or predict the occurrence of long-term complications of AGE formation and improve therapeutically the quality of vision and length of life for diabetes mellitus patients and survivors with early aging. Scientists at Innovative Vision Products, Inc. (IVP), developed lubricant eyedrops designed as a sustained-release 1% N-acetylcarnosine prodrug of L-carnosine. The eyedrops contain a mucoadhesive cellulose-based compound combined with corneal absorption promoters and glycerine in a drug-delivery system. Anti-aging therapeutics with the ophthalmic drug eyedrop formula including N-acetylcarnosine showed efficacy in the nonsurgical treatment of age-related cataracts for enrolled participants in the prospective, randomized, double-masked, placebo-controlled crossover clinical trial after controlling for age, gender, and daily activities. In a cohort in excess of 50,500 various patients seeking cutting-edge medical care, the N-acetylcarnosine topical eyedrops target therapy was demonstrated to have significant efficacy, safety, and good tolerability for the prevention and treatment of visual impairment in this older population with relatively stable patterns of causes for blindness and visual impairment. Overall, accumulated study data demonstrate that the IVP-designed new vision-saving drugs, including N-acetylcarnosine eyedrops, promote health vision and prevent vision disability from senile cataracts, primary open-angle glaucoma, age-related macular degeneration, diabetic retinopathy, and aging. N-acetylcarnosine eyedrop therapy is the crown jewel of the anti-aging medical movement and revolutionizes early detection, treatment, and rejuvenation of aging-related eye-disabling disorders. N-acetylcarnosine, as an innovative medical science tool and component of the home medicine and alternative medicine approaches, has the potential to alleviate visual impairment and its associated social, economic, and political woes for an aging population.

Vision-specific health-related quality of life in age-related maculopathy patients presenting for low vision services

Few studies have examined the effectiveness of low vision rehabilitation for age-related maculopathy (ARM) patients and its impact on vision-specific health-related quality of life (HRQoL). However, before a multi-site clinical trial can be conducted, appropriate outcome measures need to be identified for ARM patients who seek out low vision rehabilitation, including a vision-specific HR QoL instrument. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was developed to assess vision-specific HRQoL for low vision patients, including those with ARM. This study examines the performance of the NEI VFQ-25 among ARM patients who seek out low vision services and examines its relationship with visual acuity and self-reported use of low vision aids. One hundred and twenty-seven patients were recruited from a University-affiliated low vision clinic. During two telephone interviews, subjects completed the NEI VFQ-25 and a short cognitive test and provided information on general health and use of low vision aids. Additional information on visual acuity and eye health were collected from the medical record. Our results indicate that ARM patients who seek out low vision services report significant impairment in their vision-specific HRQoL. Their NEI VFQ-25 scores were lower compared to other ARM and low vision rehabilitation samples previously studied. The VFQ subscales with the largest deficits were near and distance visual acuities and psychosocial issues (near vision, distance vision, role difficulties, dependency, social functioning, mental health). These subscale scores were lower for those with greater visual acuity impairment. The VFQ subscale scores most impacted by the disease had wide variability and were higher for those who used low vision aids, suggesting that the NEI VFQ-25 is suitable for measuring further decline and treatment-related improvements. Thus, it should be strongly considered for a multi-site clinical trial on the effectiveness of low vision rehabilitation.

Cataract halos: a driving hazard in aging populations. Implication of the Halometer DG test for assessment of intraocular light scatter

OBJECTIVE AND BACKGROUND

Cataract, regardless of etiology, results in light scatter and subjective glare. Senile cataract is emerging as a crucial factor in driving safely, particularly in night driving and adverse weather conditions. The authors examined this visual impairment using a new Halometer DG test in the eyes of older adult drivers with and without cataract.

METHOD

Examined subjects consisted of n=65 older adults with cataract in one or both eyes and n=72 adult drivers who did not have a cataract in either eye. Subjects were examined for distance high contrast visual acuity (VA) and red/green disability glare (DG) with a new halo generating instrument. Subjects also completed a subjective Driving Habits Questionnaire (DHQ), designed to obtain information about driving during the past year.

RESULTS

DG increased with age of the driver. VA and Halometer DG testing of better and worse eyes prognosticated impairments which significantly affect driving performance. Cataract subjects demonstrated increased Halometer DG scores and were two to four times more likely to report difficulty with driving at night and with challenging driving situations than were cataract-free drivers.

CONCLUSION

DG is a specific cataract-induced functional age-related risk factor of driving difficulty, easily measured by a technician with a new Halometer DG device.

APPLICATION

Optometrists and ophthalmologists should incorporate Halometer DG testing in their pre-examination vision testing rooms for patients over age 55, and also perform this test on others who complain about glare. Traffic safety engineers should incorporate automotive optical-microprocessor-aided tests for DG into cars, to alert drivers of mild functional impairments and progressive degrees of DG sensitization.

Family caregiver social problem-solving abilities and adjustment to caring for a relative with vision loss

PURPOSE

To examine the prevalence of persons at risk for depression among family caregivers of visually impaired persons and the extent to which social problem-solving abilities are associated with caregiver depressive symptomatology and life satisfaction.

METHODS

Family caregivers were defined as adults who accompanied their adult relative to an appointment at a low-vision rehabilitation clinic and self-identified themselves as the primary family caregiver responsible for providing some form of assistance for their relative due to vision impairment. Demographic variables, depressive symptoms, life satisfaction, caregiver burden, and social problem-solving abilities were assessed in caregivers. The patient's visual acuity and depressive symptoms and their relationship to the caregiver's depressive symptoms and life satisfaction were also examined.

RESULTS

Ninety-six family caregivers were enrolled. Of those, 35.4% were identified as at risk for depression. Among caregivers, dysfunctional or ineffective social problem-solving abilities were significantly associated with greater depressive symptomatology and decreased life satisfaction after adjustment for caregiver burden and demographic and medical variables for both the caregiver and the visually impaired patient. Problem orientation or motivation to solving problems was also significantly associated with caregiver depression and satisfaction with life.

CONCLUSIONS

A substantial number of caregivers of visually impaired adults experience psychosocial distress, particularly among those who possess poor social problem-solving abilities. These results underscore the need for routine screening and treatment of emotional distress among individuals caring for relatives with vision impairments. Future research should examine the extent to which psychosocial interventions targeting caregiver social problem-solving skills may be useful not only in improving caregiver quality of life but also in subsequently enhancing rehabilitation outcomes for the visually impaired care recipient.

Development of a nursing home vision-targeted health-related quality of life questionnaire for older adults

PURPOSE

To develop a questionnaire assessing vision-targeted health-related quality of life in older adults residing in nursing homes.

METHODS

Using content previously identified through structured interviews with nursing home residents, the 57-item Nursing Home Vision-Targeted Health-Related Quality of Life questionnaire (NHVQoL) was drafted with nine subscales - general vision, reading, ocular symptoms, mobility, psychological distress, activities of daily living, activities/hobbies, adaptation/coping and social interaction. Construct validity and internal consistency and test-retest reliability of subscales were evaluated in a sample of adults >or=60 years old residing in nursing homes in Birmingham, Alabama, who had Mini Mental State Exam (MMSE) scores of >or=13.

RESULTS

Participants (n=189) had a mean age of 82 years (SD=7.7), were 84% women and 16% men, 24% African-American and 76% Caucasian and had resided in a nursing home for two years on average. All NHVQoL subscales were correlated with subscales from other vision-targeted and generic health-related quality of life instruments (ADVS, 0.43 to 0.85; VF-14, 0.46 to 0.84; SF-36, 0.19 to 0.43). Lower scores were associated with increased depressive symptomatology by the Geriatric Depression Scale (-0.23 to -0.59), increased mobility problems (-0.17 to -0.54), worse distance and near acuity (-0.21 to -0.51) and worse contrast sensitivity (0.20 to 0.50). All subscales had Cronbach alpha>0.95. Test-retest reliability (two-week period) for subscales ranged from 0.57 to 0.84. Subscale scores did not differ as a function of MMSE scores.

CONCLUSIONS

The NHVQoL has subscales with good internal consistency reliability and validity. Test-retest reliability is comparable to other questionnaires designed for the nursing home population. This questionnaire may ultimately be useful in understanding the personal burden of visual impairment and eye disease on quality of life and mental health in older nursing home residents and for evaluating the impact of psychosocial and eye care interventions on health-related quality of life in this population.

The Scotopic Sensitivity Tester-1 and the detection of early age-related macular degeneration1

PURPOSE

Previous research shows that dark adaptation is a marker of early age-related macular degeneration (ARMD), even when visual acuity remains good. This study evaluates whether a commercially available, off-the-shelf device for measuring dark adaptation, the Scotopic Sensitivity Tester-1 (SST-1), which uses a full-field stimulus, detects early ARMD as defined by fundus appearance. Fundus appearance is the gold standard method for defining the presence of ARMD.

METHODS

Dark adaptation was measured using the SST-1 in 12 young adults (mean age 23 years), 17 old adults with normal retinal health (mean age 69) and 19 old adults with early ARMD (mean age 74). Normal retinal health and presence of early ARMD were defined by masked grading of dilated fundus photographs using the Wisconsin Age-Related Maculopathy Grading System.

RESULTS

Older adults in normal retinal health exhibited slower dark adaptation as compared with young adults. No difference in the rate of dark adaptation was found between early ARMD patients and older adults in normal retinal health.

CONCLUSIONS

Although the SST-1 differentiated between young and older adults, it failed to detect dark adaptation abnormalities in early ARMD when referenced against older adults in normal retinal health. This may be attributable to the full-field stimulation used by the SST-1, which may be better suited for characterizing retinal degenerations affecting large retinal areas than for focal macular diseases like ARMD.

Risk of Immune Recovery Uveitis in Patients with AIDS and Cytomegalovirus Retinitis

OBJECTIVE

To evaluate the prevalence of and risk factors for immune recovery uveitis (IRU) in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis.

DESIGN

Enrollment data from a 19-clinical center cohort study.

PARTICIPANTS

Three hundred seventy-four patients with AIDS and CMV retinitis affecting 539 eyes.

METHODS

Patients with AIDS were enrolled at 19 United States AIDS ophthalmology clinics. Data were collected by interview, review of medical records, ophthalmic examination, and phlebotomy.

MAIN OUTCOME MEASURE

Immune recovery uveitis.

RESULTS

Thirty-six patients (9.6%) were diagnosed with IRU involving 50 eyes. The CD4+ T-cell count of 31 of these had risen by > or =50 cells per microliter above nadir to a level > or = 100 cells per microliter (immune recovery), making up 17.6% of the patients known to have immune recovery after diagnosis of CMV retinitis (95% confidence interval, 12.3%-24.1%). No patients with IRU were observed to have active retinitis or detectable CMV DNA in peripheral blood (P<0.001 and P<0.001 with respect to patients without IRU). Other factors associated with IRU were > or =25% retinal area (odds ratio [OR], 2.72; P = 0.014) or posterior pole involvement with CMV retinitis (odds ratio, 0.43; P = 0.039), treatment with intravitreous injection of cidofovir (OR, 10.6 with respect to eyes never exposed to intravitreous or IV cidofovir; P<0.001), and male gender (OR, 0.26; P = 0.012). More eyes with IRU had visual acuity (VA) of 20/50 or worse (38.0% vs. 26.3%, P = 0.077) relative to eyes without IRU, but the proportions with VA of 20/200 or worse were similar (14.0% vs. 13.8%, P = 0.96). Eyes with IRU more commonly had cystoid macular edema (CME) (45.5% vs. 3.7%, P<0.001) and epiretinal membrane (48.9% vs. 13.3%, P<0.001) than eyes without IRU.

CONCLUSIONS

Among eyes of patients with immune recovery, the prevalence of IRU is substantial. Eyes with IRU have a high risk of additional morbidity over and above that seen with CMV retinitis, with several-fold higher risk of CME and epiretinal membrane. Large CMV lesions and use of intravitreous cidofovir are risk factors for IRU.

Cytokine profile in response to Cytomegalovirus associated with immune recovery syndrome after highly active antiretroviral therapy

BACKGROUND

Several changes have occurred in the presentation and course of cytomegalovirus (CMV) retinitis in patients with AIDS since the introduction of HAART (highly active antiretroviral therapy). In some individuals who take HAART, retinitis is kept under control even after the discontinuation of anti-CMV therapy. However, many of these patients develop intraocular inflammation. Uveitis, cataract, vitreitis, cystoid macular edema, epiretinal membrane, and disc edema may occur in patients with immune recovery syndrome (IRS).

METHODS

We evaluated the CMV-specific immune response in 55 patients by assessing CMV-specific lymphocyte proliferation, cytotoxicity, and cytokine production and correlated it with the clinical outcome.

RESULTS

Our data suggest that control of CMV retinitis is associated with acquisition of cytotoxic and lymphoproliferative responses to CMV. In addition, the upsurge of macular and disc edema seems associated with the production of interleukin-4 and tumor necrosis factor-alpha, whereas vitreitis is associated with the production of interleukin-2 and interferon-gamma.

INTERPRETATION

The type of T-cell response that develops after HAART may determine the side effects of immune recovery and these effects are predictable based on the lymphokine profile produced by CMV-specific cells.

Impact of aging and age-related maculopathy on inactivation of the a-wave of the rod-mediated electroretinogram

This study examined the impact of aging and age-related maculopathy (ARM) on the inactivation of phototransduction in rod photoreceptors by measuring the recovery of the a-wave using a paired flash electroretinogram technique. Measurements were made on 32 older adults in normal retinal health, 25 with early ARM, 7 with late ARM, and 20 young adults for comparison purposes. ARM presence and severity were defined by the Wisconsin Age-Related Maculopathy Grading System based on grading of fundus photographs. The inactivation of rod phototransduction exhibited an aging-related slowing. Those with early ARM did not exhibit inactivation slowing over and above what would be expected based on normal retinal aging. Persons in the late stages of ARM exhibited dramatic slowing in inactivation kinetics.

Performance of community-based glaucoma screening using Frequency Doubling Technology and Heidelberg Retinal Tomography

PURPOSE

To assess the performance of a community-based glaucoma screening algorithm in the general population.

METHODS

A total of 659 individuals aged 50-90 years were screened for glaucoma. Presenting visual acuity, family history of glaucoma, FDT perimetry, and HRT tests were assessed. Additional samples of participants served as control groups. Participants identified as glaucoma positive received a full ophthalmic examination. Based on this exam a consensus diagnosis was made which served as the gold standard.

RESULTS

The optimal screening strategy combining visual acuity and family history with FDT and HRT had sensitivities, specificities, positive predictive values and negative predictive values of 96.8%, 89.7%, 31.9%, and 99.8% respectively for detecting glaucoma.

CONCLUSIONS

By combining assessments of presenting visual acuity and family history of glaucoma with Frequency Doubling Technology perimetry and Heidelberg Retina Tomography, we devised a community glaucoma-screening algorithm that showed a high sensitivity and specificity for detecting glaucoma in the general population.

Incorporating vision and hearing tests into aged care assessment: methods and the pilot study

PURPOSE

Vision and hearing impairments are frequent in older people and may contribute to their reliance on aged care services. This study aims to assess whether incorporating vision and hearing screening into routine aged care assessments and provision of appropriate health care services will influence health outcomes of older individuals.

METHODS

The proposed project is a 2 x 2 factorial design randomized controlled trial. The pilot study recruited 208 participants aged 65+ years attending an aged care assessment center at Westmead Hospital, Sydney, who were randomly allocated to one of four groups: vision and hearing tests, vision tests only, hearing tests only, or neither. Face-to-face interviews with all participants were conducted. Questionnaires included Activity of Daily Living (ADL), 36-item Short-Form health survey (SF-36), Mini-Mental State Exam (MMSE) and questions about use of health care and community support services. Participants will be re-examined after 12 months to assess changes over time in quality-of-life, physical and cognitive function, incident falls and use of health and community aged care services.